For more than a century, substantial racial and ethnic inequities in perinatal health outcomes have persisted despite technical clinical advances and changes in public health practice that lowered the overall incidence of morbidity. Race is a social construct and not an inherent biologic or genetic reality; therefore, racial differences in health outcomes represent the consequences of structural racism or the inequitable distribution of opportunities for health along racialized lines. Clinicians and scientists in obstetrics and gynecology have a responsibility to work to eliminate health inequities for Black, Brown, and Indigenous birthing people, and fulfilling this responsibility requires actionable evidence from high-quality research. To generate this actionable evidence, the research community must realign paradigms, praxis, and infrastructure with an eye directed toward reproductive justice and antiracism. This special report offers a set of key recommendations as a roadmap to transform perinatal health research to achieve health equity. The recommendations are based on expert opinion and evidence presented at the State of the Science Research Symposium at the 41st Annual Pregnancy Meeting of the Society for Maternal-Fetal Medicine in 2021. Recommendations fall into 3 broad categories—changing research paradigms, reforming research praxis, and transforming research infrastructure—and are grounded in a historic foundation of the advances and shortcomings of clinical, public health, and sociologic scholarship in health equity. Changing the research paradigm requires leveraging a multidisciplinary perspective on structural racism; promoting mechanistic research that identifies the biologic pathways perturbed by structural racism; and utilizing conceptual models that account for racism as a factor in adverse perinatal outcomes. Changing praxis approaches to promote and engage multidisciplinary teams and to develop standardized guidelines for data collection will ensure that paradigm shifts center the historically marginalized voices of Black, Brown, and Indigenous birthing people. Finally, infrastructure changes that embed community-centered approaches are required to make shifts in paradigm and praxis possible. Institutional policies that break down silos and support true community partnership, and also the alignment of institutional, funding, and academic publishing objectives with strategic priorities for perinatal health equity, are paramount. Achieving health equity requires shifting the structures that support the ecosystem of racism that Black, Brown, and Indigenous birthing people must navigate before, during, and after childbearing. These structures extend beyond the healthcare system in which clinicians operate day-to-day, but they cannot be excluded from research endeavors to create the actionable evidence needed to achieve perinatal health equity.